Bottom Line:
Coronary artery fistulae represent the most frequent congenital anomalies of the coronary arteries, but multiple bilateral fistulae are a rare condition.Transcatheter closure of fistulae using coils is preferred as an effective and safe alternative to surgery.Here we report the case of a patient with congenital coronary artery fistulae arising from both the left and right coronary arteries draining individually into the right pulmonary artery treated successfully with a transcatheter approach.

ABSTRACTCoronary artery fistulae represent the most frequent congenital anomalies of the coronary arteries, but multiple bilateral fistulae are a rare condition. Current therapeutic options for symptomatic patients are percutaneous closure and cardiac surgery. Transcatheter closure of fistulae using coils is preferred as an effective and safe alternative to surgery. Here we report the case of a patient with congenital coronary artery fistulae arising from both the left and right coronary arteries draining individually into the right pulmonary artery treated successfully with a transcatheter approach.

Figure 0002: Transcatheter closure of the fistulae with coils. Tortuous fistulae between the side branch of the left circumflex coronary artery and the right pulmonary artery (A), posterolateral branch (B) and proximal branch (C) of the right coronary artery have been closed with coils

Mentions:
The procedure was carried out under local anesthesia with sedation and a 6 Fr sheath was inserted in the right femoral artery. The left main coronary artery was cannulated with a 6 Fr extra back-up 3.75 guiding catheter (Launcher, Medtronic Inc, Minneapolis, MN, USA), and was deeply engaged to access the distal Cx. Initially, a hi-torque Whisper LS guidewire (Abbott Laboratories, Abbott Park, IL, USA) was negotiated from the Cx to PA through the fistula. Embolization coils (2.5 mm × 3 cm, 3.0 mm × 4 cm, and 2.0 mm × 4 cm; Barricade Coil System, Blockade Medical, Irvine, CA, USA) were delivered to the distal vessel via a micro catheter (Vasco Plus Braided Microcatheter, Balt Extrusion, Montmorency, France). Control angiography demonstrated occlusion of the fistulous communication between the Cx and PA (Figure 2A). Then, the right coronary artery was cannulated with a 6 Fr JR 4.0 guiding catheter (Launcher, Medtronic Inc, Minneapolis, MN, USA), and was deeply engaged to access the distal RCA. A 0.014’’ hydrophilic guidewire (Asahi Sion, Abbott Laboratories, Abbott Park, IL, USA) was used to pass through the fistula between the posterolateral branch and PA. Embolization coils (4.0 mm × 6 cm and 2.0 mm × 4 cm; Barricade Coil System, Blockade Medical, Irvine, CA, USA) were delivered and maintained successful closure of the fistula (Figure 2B). Last of all, the fistulous connection between the proximal RCA and PA was wired with a hydrophilic guidewire (Whisper LS, Abbott Laboratories, Abbott Park, IL, USA). It was occluded using 3.0 mm × 8 cm, 2.0 mm × 4 cm, and 3.0 mm × 4 cm coils (Barricade Coil System, Blockade Medical, Irvine, CA, USA) (Figure 2C). There were no major complications such as coil migration, dissection of the feeding vessel or of native coronary arteries, myocardial infarction, death, stroke or infection. The patient's hemodynamics remained stable during the procedure, and there were no electrocardiographic changes indicative of myocardial ischemia. Cardiac enzymes remained at normal levels after the procedure. The patient reported resolution of his symptoms, and he was discharged on the following day. He has been followed up clinically 3 months after the procedure and he has been asymptomatic.

Figure 0002: Transcatheter closure of the fistulae with coils. Tortuous fistulae between the side branch of the left circumflex coronary artery and the right pulmonary artery (A), posterolateral branch (B) and proximal branch (C) of the right coronary artery have been closed with coils

Mentions:
The procedure was carried out under local anesthesia with sedation and a 6 Fr sheath was inserted in the right femoral artery. The left main coronary artery was cannulated with a 6 Fr extra back-up 3.75 guiding catheter (Launcher, Medtronic Inc, Minneapolis, MN, USA), and was deeply engaged to access the distal Cx. Initially, a hi-torque Whisper LS guidewire (Abbott Laboratories, Abbott Park, IL, USA) was negotiated from the Cx to PA through the fistula. Embolization coils (2.5 mm × 3 cm, 3.0 mm × 4 cm, and 2.0 mm × 4 cm; Barricade Coil System, Blockade Medical, Irvine, CA, USA) were delivered to the distal vessel via a micro catheter (Vasco Plus Braided Microcatheter, Balt Extrusion, Montmorency, France). Control angiography demonstrated occlusion of the fistulous communication between the Cx and PA (Figure 2A). Then, the right coronary artery was cannulated with a 6 Fr JR 4.0 guiding catheter (Launcher, Medtronic Inc, Minneapolis, MN, USA), and was deeply engaged to access the distal RCA. A 0.014’’ hydrophilic guidewire (Asahi Sion, Abbott Laboratories, Abbott Park, IL, USA) was used to pass through the fistula between the posterolateral branch and PA. Embolization coils (4.0 mm × 6 cm and 2.0 mm × 4 cm; Barricade Coil System, Blockade Medical, Irvine, CA, USA) were delivered and maintained successful closure of the fistula (Figure 2B). Last of all, the fistulous connection between the proximal RCA and PA was wired with a hydrophilic guidewire (Whisper LS, Abbott Laboratories, Abbott Park, IL, USA). It was occluded using 3.0 mm × 8 cm, 2.0 mm × 4 cm, and 3.0 mm × 4 cm coils (Barricade Coil System, Blockade Medical, Irvine, CA, USA) (Figure 2C). There were no major complications such as coil migration, dissection of the feeding vessel or of native coronary arteries, myocardial infarction, death, stroke or infection. The patient's hemodynamics remained stable during the procedure, and there were no electrocardiographic changes indicative of myocardial ischemia. Cardiac enzymes remained at normal levels after the procedure. The patient reported resolution of his symptoms, and he was discharged on the following day. He has been followed up clinically 3 months after the procedure and he has been asymptomatic.

Bottom Line:
Coronary artery fistulae represent the most frequent congenital anomalies of the coronary arteries, but multiple bilateral fistulae are a rare condition.Transcatheter closure of fistulae using coils is preferred as an effective and safe alternative to surgery.Here we report the case of a patient with congenital coronary artery fistulae arising from both the left and right coronary arteries draining individually into the right pulmonary artery treated successfully with a transcatheter approach.

ABSTRACTCoronary artery fistulae represent the most frequent congenital anomalies of the coronary arteries, but multiple bilateral fistulae are a rare condition. Current therapeutic options for symptomatic patients are percutaneous closure and cardiac surgery. Transcatheter closure of fistulae using coils is preferred as an effective and safe alternative to surgery. Here we report the case of a patient with congenital coronary artery fistulae arising from both the left and right coronary arteries draining individually into the right pulmonary artery treated successfully with a transcatheter approach.